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soon STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A ° COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ® T PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑) 4 AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION& ADDRESS-(MUST BE COMPLETED) to DBAOR FACILITY NAME NAMEOFOPERATOR ` rar_T_MarinP Sa1P9 ADDRESS NEAREST CROSS STREET PARCEL#(OPTIONAL) 353 ToatP -Road , RnRC3 CITY NAME STATE ZIP CODE SITE PHONE#WITH AREA CODE Tracy CA 95376 209 835-6565 ✓ BOX TOINDICATE XXCORPORATION 0 INDIVIDUAL = PARTNERSHIP E=I LOCAL AGENCY 0 COUNTY-AGENCY O STATE-AGENCY Q FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS O 1 GAS STATION 2 DISTRIBUTORO ✓ IF INDIAN 1#OF TANKS AT SITE E.P.A. I.D.#(optimal) RESERVATION 2 ❑ 3 FARM ❑ 4 PROCESSOR qgC S OTHER OR TRUST LANDS CAC 000 764 064 EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)•optional DAYS: NAME(LAST,FIRST) PHONE#WITH AREA CODE DAYS: NAME(LAST,FIRST) Lit e, William__�Q4__ _ Little, william 209 956-0264 NIGHTS: NAME(LAST.FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST.FIRST) 209 835-4476 Joe Toste Jr. 209 835-4476 Joe Toste Jr. PHONE 4 WITH AREA COOP II. PROPERTY OWNER INFORMATION- MUST BE COMPLETED NAME CARE OF ADDRESS INFORMATION Joe T2 - Toste Farms 24 ac CA 95376 iM MAILING OR STREET ADDRESS ✓ boabkaN Q INDIVIDUAL 0 LOCAL-AGENCY C71 STATEAGENCY 2460 Toste Road X$GORPORATION [�] PARTNERSHIP 0 COUNTY-AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP GODE PHONE#WITH AREA CODE Tracv CA 95376 209 835-4476 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAME OF OWNER CARE OF ADDRESS INFORMATION Toste Farms 2420 Toste Road, TRac , CA 95376 MAILING OR STREET ADDRESS ✓ b0r biWx.ta O INDIVIDUAL [_1 LOCAL-AGENCY L=1 STATE-AGENCY 2_420 Toste Road, CORPORATION D PARTNERSHIP E] COUNTY-AGENCY Q FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE Tracy CA 95376 209 835- 4476 IV.BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ 1414-1- V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)-IDENTIFY THE METHOD(S) USED ✓ ba bindicate L-1 1 SELF-INSURED 2 GUARANTEE 0 3INSURANCE L::]d SURETY BONG El 5 LETTMCFCREDIT O 6 EXEMPTION 71 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.RR III. THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATU ) APPLICANTS TITLE DATE MONTH/DAYNEAR William Little Geolo ost October 07 1996 LOCAL AGENCY USE ONLY p COUNTY# JURISDICTION# FACILITY It 4&43 TO I _ 3 r s LOCATION CODE -OPTIONAL CENSUS TRACT# NA -OPTIOL SUPVISOR DISTRICTCODE -OPTIONAL THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. RM A(12 91) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS FOR0033A86